Venous access during neonatal emergencies in the delivery room (DR) can be accomplished through an umbilical venous catheter (UVC) or an intraosseous (IO) access. Preference of one over the other is unclear. We wanted to evaluate practioners’ views.
Trang 1R E S E A R C H A R T I C L E Open Access
regarding vascular emergency access in
newborn infants in the delivery room: a
national survey
Bianca Haase*, Laila Springer and Christian Friedrich Poets
Abstract
Background: Venous access during neonatal emergencies in the delivery room (DR) can be accomplished through
an umbilical venous catheter (UVC) or an intraosseous (IO) access Preference of one over the other is unclear We wanted to evaluate practioners’ views
Methods: An anonymous online questionnaire was circulated to healthcare professionals with different background and experience, all working in neonatal intensive care units in Germany The web-based survey consisted of 13 questions and data collection was performed using an online tool
Results: We received 502 completed questionnaires, 152 (30%) were from neonatologists, the remainder from residents, fellows and neonatal nurses For resuscitation of term newborns in the DR 61% of neonatologists vs 53%
of non-neonatologists were in favour of UVC instead of an IO as an emergency access UVC placement was rated (very) difficult to impossible by 60% of neonatologists and 90% of non-neonatologists (p < 0.05) All respondents cited lack of experience as the main reason for feeling reluctant to place an UVC or IO access, the latter only being taken into consideration in term infants
Conclusions: UVC placement in the DR is rated more often difficult to use by non-neonatologists than by neonatologists, apparently related to lack of experience IO access was only considered for resuscitating term infants due to lacking practice and missing approval for birth weights < 3000 g Frequent training might improve these clinical skills
Keywords: Delivery room, Resuscitation, UVC placement, Intraosseous access, Venous access
Background
In the crucial first postnatal minutes the establishment
of a venous access is essential especially in very
prema-ture infants and term newborns with circulatory
com-promise This, however, may be challenging and time
consuming [1] and untreated arterial hypotension or
persistent bradycardia may ensue [2] The 2015 ERC
(European Resuscitation Council) guidelines for new-born resuscitation recommend an umbilical venous catheter for the administration of drugs (UVC) [3] However, placing an UVC might be challenging and takes longer than an intraosseous (IO) access especially for untrained personnel [4] Moreover, UVC placement
as an invasive procedure entails additional risks, e.g thrombosis [5] and necrotizing enterocolitis (NEC) [6]
If an intravenous vascular access is unsuccessful, the IO access seem to be a good alternative during resuscitation
© The Author(s) 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the
* Correspondence: bianca.haase@med.uni-tuebingen.de
Department of Neonatology, University Children ’s Hospital Tuebingen,
Calwerstraße 7, 72076 Tuebingen, Germany
Trang 2of critically ill neonates in comparison to the more
so-phisticated UVC placement procedure, especially for
un-trained personnel [7]
Therefore, IO cannulas should be available in all
neo-natal units and their application should be trained [8] It
is a non-natural access pathway, however, with a
compli-cation rate of 13% [9]
In order to verify whether prevailing practice during
DR management corresponds to current guidelines, we
developed a national online survey for healthcare
profes-sionals with different background and experience with a
focus on the most commonly used access routes in a
neonatal emergency setting
Methods
Study design and consent
An anonymous web-based online survey was created
using SurveyMonkey (San Mateo, USA) and circulated
between 11/2018 and 1/2019 after approval by the Ethics
Committee of Tuebingen University Hospital (871/
2018) Since this is an anonymous data analysis of the
SurveyMonkey platform, consent was given by
voluntar-ily participation the questionnaire
Data collection
Data were collected using a web-based survey (Survey
Monkey, San Mateo, USA), which was distributed
among healthcare professionals via e-mail While
re-sponses were anonymous, participants were asked to use
an online link to receive a unique token to complete the
survey, which was announced at neonatal workshops
organised by the authors’ institution with the request to
distribute the link among colleagues There was no
fi-nancial incentive for taking part in the survey
Questionnaire
The questionnaire consisted of 13 questions (in German)
and had been validated by 10 independent physicians
and 10 nurses with regard to its comprehensibility,
suit-ability of its pre-formulated answers, and simplicity It
differentiated between routine and emergency situations
during DR management Both, UVC and IO access, were
evaluated for an emergency situation in the DR; the
placement of an UVC was also evaluated in a
non-emergency setting in non-depressed preterm infants
Non-emergency situations are routine situations in the
DR with the need of a central line for administration of
glucose or medications such as caffeine in extremely
preterm infants There was no evaluation for
out-of-hospital use The questionnaire contained single choice
and multiple-choice responses; for 13 questions, an
op-tion to select“others” or a free-text field was also offered
(Table1) Questions could be answered with“very easy,”
“easy”, difficult”, “very difficult” or “impossible”, but
ratings were subsequently collapsed into “(very) easy” and “(very) difficult” In order to standardize termin-ology, we adapted the German Level I-III system for neonatal care to the American classification Centres were divided into tertiary-level neonatal intensive care units (NICUs) Level III centres (in Germany called‘Level
I centre’) and non-tertiary special care nurseries (SCNs) (in Germany classified as ‘Level II and Level III units’; Table1)
Data analysis
Responses were imported from the SurveyMonkey data-base to SPSS version 25 (IBM, Chicago, IL) Descriptive statistics were generated for key variables including edu-cational degrees of healthcare professionals, NICU level and annual number of deliveries Categorical data were summarized and shown as counts and percentages Or-dinal data were analysed using Mann-Whitney U-test A p-value (two-sided) of < 0.05 was considered to represent statistical significance
Results
We received 502 completed questionnaires, including
152 (30%) from neonatologists (Table 2) 395 respon-dents (79%) worked in tertiary-level NICUs, the remain-der in non-tertiary SCNs Approximately one half (54%) worked in hospitals with≥ 2000 deliveries per year 321 respondents (64%) indicated that they had at least three years of work experience in neonatology
50% of respondents stated they had never applied an IOC by themselves and 30% had no previous experience
in establishing an UVC access
In agreement with the above guidelines, for DR manage-ment 61% of neonatologists vs 53% of non-neonatologists were in favour of UVC placement instead of an IO access for the resuscitation of a term newborn In tertiary-level NICUs vs non-tertiary SCNs, 57% vs 50%, respectively, of respondents preferred an UVC placement in the DR While evaluating emergency UVC placement in the
DR, almost 90% of non-neonatologists or respondents working in non-tertiary SCNs rated the procedure as (very) difficult to impossible, and even 60% of experi-enced neonatologists or respondents from tertiary-level NICUs considered it (very) difficult to impossible (p < 0.05) (Fig 1) In all responses, lack of experience was cited as the main reason for a reluctance to place an UVC (53%)
Emergency application of an IO access (Fig 2) in the
DR was rated (very) easy by 72% of neonatologists vs 65% of non-neonatologists, although 50% had no previ-ous real-life experience with it, with this proportion be-ing similar in tertiary-level NICUs versus non-tertiary SCNs Reasons given for preference of an UVC over
Trang 3Table 1 Questions of the online survey
1.1 Professional group you belong to (SC)
e head of the neonatal department (neonatologist)
1.2 Your professional experience in years (SC)
1.3 Your hospital ’s NICU level of care (based on the German G-BA nomenclature) (SC)
a Level I (equivalent to tertiary unites); admitting all infants
b Level II; admitting infants with a birthweight of > 1250 g or > 29 wk gestation
c Level III (equivalent to international NICU level I); admitting infants > 1500 g or
> 32 wk gestation
1.4 Number of deliveries per year in your hospital (SC)
2.1 How many UVC have you placed successfully? (SC)
2.2 On a scale of 1 –5, how do you rate the feasibility of UVC insertion in a routine non-emergency setting in the DR? (SC)
2.3 On a scale of 1 –5, how do you rate the feasibility of UVC insertion in an emergency setting in the delivery room? (SC)
2.4 What do you think are the most common problems during an UVC placement? (MC)?
e others (please specify)
3.1 How many IOC have you performed successfully?
3.2 On a scale of 1 –5, how would you rate the feasibility of inserting an IOC in an emergency situation in the DR? (SC)
3.3 What do you think is(are) the most common problem(s) during IOC insertion? (MC)
Trang 4IOC included avoidance of pain (24%), a potential for
bone injury (32%), catheter malposition (40%) or lack of
experience (56%)
In a non-emergency setting in the DR, UVC placement
was evaluated to obtain a basic assessment of this
pro-cedure 70% of responding neonatologists respectively
66% of respondents from tertiary centres rated the
appli-cation of routine UVC placement as (very) easy, whereas
only 43% of non-neonatologists (p < 0.05; Fig 3),
re-spectively 32% of non-tertiary centres, rated it as very
easy (data not shown)
Discussion
To our knowledge, this is the first national survey
evalu-ating current opinions of healthcare professionals in
Germany regarding placement of an UVC or IO access
in an emergency setting in the DR In accordance with
current guidelines, responders preferred an UVC over
IO access during transition at birth
Only a narrow majority of 60% was in favour of an
UVC in emergency situations in the DR, which could be
due to the fact that establishing an IO access was
classi-fied as (very) easy by 67% of respondents, even though
only 50% had ever implemented one themselves
Respondents to our survey rated the level of difficulty
according to their own level of training and experience,
which might be a reason why, contrary to current
recommendations, with less experience the affinity to IO access increased While many extremely preterm infants born in tertiary centres need a central venous line access during their subsequent neonatal intensive care [10], the UVC is often placed either in the delivery room or shortly afterwards in the NICU [11], as it provides a painless and reliable vascular access for preterm infants avoiding the skin punctures needed for other forms of vascular access [12]
However, as long as the UVC remains the recommend access in DR management in international guidelines [3] and as long as there is a lack of a device that simplifies the inserting procedure, consistent training should be enforced [4]
An umbilical cord simulator may offer a realistic train-ing with real human cords [13] and should be preferred
to manikins with an artificial and more unrealistic um-bilical cord [14]
Another reason for placing an UVC is that high plasma levels of epinephrine can be reached faster and more reliably via a centrally positioned UVC than via the endotracheal route [15] and, according to the 2015 ERC Guidelines, drugs should be applied this way [3] It remains unclear whether the same is true for an IO ac-cess [16] Initial studies (excluding neonatal patients) showed no significant interaction between the access route and study drug outcomes [16] However, IO access
in neonates has not yet been investigated in detail, only case series, post-mortem studies and simulation studies could be identified and showed a lack of evidence in this patient group [8]
However, successful placement of an UVC took 46 s longer than application of an IO access in a simulation study [17] In an emergency situation in the DR, this delay may be responsible for the increasing preference of an IO access during the resuscitation of term neonates, as con-firmed by our survey Therefore, such IO access should be available, trained and taken into consideration on all neo-natal units if other access routes have failed [18]
Previous experience with IO access significantly re-duced reluctance and increased the willingness to use an
IO access as the first choice for emergency vascular access [19]
Table 1 Questions of the online survey (Continued)
4.1 In an emergency situation in the delivery room, which access route would you consider for a newborn weighing 4000 g (with pronounced centralisation)? (SC)
4.2 For the initial delivery room treatment of a 500 g premature baby, which access route would you prefer (after failed placement
of a peripheral venous line)? (SC)
Answers possible as MC Multiple Choice, SC Single Choice and free answering fields if named: Others (please specify)
Table 2 Respondents of the online survey
Survey consisting of 13 questions; respondents 502
Respondents working in Level III centres
Respondents working in Level II centres
Respondents working in Level I centres
Data are displayed as counts and percentages NICU Neonatal Intensive
Care Unit
Trang 5Besides that, the IO access is a non-natural access
route with a complication rate of 13% [9] such as
frac-tures, limb ischaemia and need for amputation [20, 21]
The complications are higher in smaller infants due to
the small margin of error when inserting an IO device
[22].The“risk of a bone injury” and “causing pain” were
the main reasons cited in our survey why respondents
would not apply an IO access
A recent trial in 16 stillborns showed success rates in
newborns between 40% and 60%, depending on the
nee-dle used [22] However, checking the correct position of
an IO access with a CT-scan is difficult to accomplish
during neonatal resuscitation
Moreover, a major problem of UVC placement is malposition, which is associated with a higher risk of thrombosis [5] and NEC [6] In our survey, a risk of malposition was mentioned 72 times in the free-text option when respondents were asked to mention most common problems during UVC insertion
This leads to the first limitation of our study: only few multiple-choice responses were used, thus “mal-position” was not offered as a response Furthermore,
we did not compare blunt hollow cannulas with um-bilical venous catheters, this might have been interest-ing especially in the context of resuscitation in the DR
Fig 1 Compares the opinion of neonatologists respectively non-neonatologists of the practicability of an UVC in an emergency setting in the delivery room (p < 0.05)
Fig 2 Compares the opinion of neonatologists respectively non-neonatologists on the difficulty in placing an intraosseous access in an
emergency setting in the delivery room (p > 0.05) (cave: weight > 3000 g) There was no comparison between routine and emergency setting
Trang 6Additionally, we included fewer open questions to
minimize the risk of having a low participation rate
Another limitation is that distribution of the
question-naire was random and therefore not all neonatal centres
might have been reached This was due to the fact that
there is no general email list for specified healthcare
pro-fessionals in neonatology, which may have introduced a
selection bias In addition to that, GDPR (General Data
Protection Regulation) rules dictated anonymity of the
e-mail responses received, prohibiting us from gathering
data on the number of participants and refusals to
participation
Nevertheless, a strength of our study is a high number
of respondents during the 3-month period so that we
can still present a broad picture of opinions
Conclusions
UVC placement in an emergency setting in the DR was
rated more difficult by non-neonatologists compared to
neonatologists in this German online survey, mainly due
to the perceived difficulties in performing an UVC
place-ment and lack of experience; both of which can only be
improved by frequent training until there is a device that
simplifies the sophisticated and challenging process of
placing a UVC
For this reason, inserting an IO access, which is much
easier to accomplish, may continue to be justified during
resuscitation of term neonates and should be trained
and available in all neonatal units
Abbreviations
CT-scan: Computer Tomography Scan; DR: Delivery room;
ERC: European Resuscitation Council; GDPR: General Data Protection
IO: Intraosseous; NEC: Necrotizing enterocolitis; NICU: Neonatal intensive care unit; SCN: Special Care Nursery; UVC: Umbilical venous catheter
Acknowledgements Not applicable.
Authors' contributions
BH conceived the study idea, created the online survey, collected and analysed the data and wrote the first draft of the manuscript CFP and LS revised the manuscript for important intellectual input All authors participated in critical revision of the manuscript for important intellectual content All authors approved the final manuscript as submitted and agree
to be accountable for all aspects to the work.
Funding
BH was supported by an intramural AKF- grant (Angewandte Klinische Forschung; number E0327039) from the Faculty of Medicine, University of Tübingen which enabled her partial release from clinical work as part of the research funding programme Additional we acknowledge financial support
by Open Access Publishing Fund of University of Tübingen The University of Tuebingen patented an invention of BH for placing an umbilical venous catheter Open Access funding provided by Projekt DEAL.
Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate The research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.
Since this is an anonymous data analysis of the SurveyMonkey platform, consent was given by voluntarily participation the questionnaire The study was approved bythe institutional Ethics Committee of the University of Tuebingen (approvalnumber: 871/2018).
Consent for publication Not applicable.
Competing interests
BH is founder of Neotools (neotools GmbH, Erkelenz, Germany) The other Fig 3 Compares the opinion of neonatologists respectively neonatologists on the difficulty in placing a UVC in the delivery room in a non-emergency setting in non-depressed preterm infants (p < 0.05)
Trang 7Received: 2 April 2020 Accepted: 12 August 2020
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